Pablo Demelo-Rodríguez, a,∗ María Olmedo Samperio, Daniel

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Letters to the Editor / Arch Bronconeumol. 2015;51(12):656–665
Pablo Demelo-Rodríguez,a,∗ María Olmedo Samperio,a
Daniel Germán Gaitán Tocora,a Juan Carlos Cano Ballesteros,a
Juan Antonio Andueza Lillob
659
b Servicio de Urgencias, Hospital General Universitario Gregorio
Marañón, Madrid, Spain
∗ Corresponding
a
Departamento de Medicina Interna, Hospital General Universitario
Gregorio Marañón, Madrid, Spain
author.
E-mail address: pbdemelo@hotmail.com (P. Demelo-Rodríguez).
Paraneoplastic cerebellar degeneration
associated with small cell neuroendocrine
mediastinal carcinoma夽
Degeneración cerebelosa paraneoplásica asociada a carcinoma
neuroendocrino mediastínico de células pequeñas
To the Editor,
We report the case of a 69-year-old woman admitted with a
7-month history of anorexia and asthenia, along with unsteadiness, vomiting, tremor and double vision. She also reported a
1-month history of dyspnea and voice changes. On examination,
she presented a bitonal voice, ataxic gait and dysmetria, with intention tremor in the left arm. Magnetic resonance imaging (MRI)
of the head revealed a small lacunar infarction, which did not
explain the clinical symptoms. Blood work, biochemistry, proteins,
immunoglobulins, thyroid profile, vitamin B12 , vitamin E and folate
were normal, and serologies for HIV, hepatitis, cytomegalovirus,
Epstein–Barr virus, syphilis and Borrelia were all negative. Cerebrospinal fluid cytochemistry was also normal. Carcinoembryonic
antigen and neurospecific enolase tumor markers were elevated at
30.4 ng/ml (0–5 ng/ml) and 21.7 ng/ml (0–16 ng/ml), respectively.
Computed tomography (CT) of the chest and abdomen revealed
a mass in the upper mediastinum, measuring 70 mm×40 mm,
suggestive of clustered lymphadenopathy. An immune-mediated
process was suspected, so antinuclear antibodies and onconeuronal antibodies were tested, but these were negative, with
anti-glutamic acid decarboxylase antibodies (anti-GAD) 2.4 U/ml
(0–5 U/ml) and anti-acetylcholine receptor antibodies 0.01 nmol/l
(0–0.1 nmol/l). F-18 fluorodeoxyglucose uptake on a positron emission tomography scan suggested malignancy, so a biopsy was
obtained by mediastinoscopy. The pathology report confirmed
small cell neuroendocrine carcinoma of the thymus, positive for
chromogranin and synaptophysin (Fig. 1). A scintigraphy (octreoscan) was then performed to complete the examination, showing
111 indium-pentetreotide uptake in the tumor and supraclavicular
lymph node metastases. The patient underwent surgical resection
and received chemotherapy with carboplatin and etoposide. She
achieved full remission of the cancer and almost complete resolution of her neurological symptoms, although tremor at rest did
persist.
Neuroendocrine tumors (NET) are rare cancers, generally found
in the gastrointestinal tract, although they may occur in the lung,
thymus, ovaries and non-parenchymatous tissue. Thymic NETs
account for less than 5% of mediastinal tumors.1 Approximately
30% are malignant, although this rate rises to 82% if they are located
in the thymus.1 They present as a mediastinal mass mainly in
夽 Please cite this article as: Serrano-Martínez JL, Zamora-Pasadas M, Redondo-Orts
M. Degeneración cerebelosa paraneoplásica asociada a carcinoma neuroendocrino
mediastínico de células pequeñas. Arch Bronconeumol. 2015;51:659–660.
Fig. 1. Histology slide at 30× amplification with chromogranin immune staining,
showing tumor cell nests separated by fibrovascular tracts.
patients aged 30–50 years, and are 3 times more common in men.2
Local clinical manifestations can range from dysphonia or dyspnea
to superior vena cava syndrome, and one-third of patients have
endocrine symptoms associated with multiple endocrine neoplasia
syndrome. CT, MRI and 123 I-metaiodobenzylguanidine scintigraphy are useful, but the octreoscan is the most sensitive procedure
(71%–100%) for detecting NETs, depending on the somatostatin
receptors expressed by the tumors. Histology examination shows
cell nests with fibrovascular tracts, positive for neuroendocrine
markers such as chromogranin, synaptophysin and neuroenolase.
Paraneoplastic cerebellar degeneration (PCD) is the most common
paraneoplastic neurological syndrome. In 18%–50% of cases, no
antibodies are identified,3 and in early stages of the disease, MRI is
normal.4 It is associated with several neoplastic processes, including thymic NETs.5
In view of the favorable response to specific cancer treatment,
we classified our case as seronegative PCD associated with thymic
NET.
References
1. Duh QY, Hybarger CP, Geist R, Gamsu G, Goodman PC, Gooding GA, et al. Carcinoids associated with multiple endocrine neoplasia syndromes. Am J Surg.
1987;154:142–8.
2. Suster S, Moran CA. Neuroendocrine neoplasms of the mediastinum. Am J Clin
Pathol. 2001;115:17–27.
3. Ducray F, Demarquay G, Graus F, Decullier E, Antoine JC, Giometto B, et al. Seronegative paraneoplastic cerebellar degeneration: the PNS Euronetwork experience.
Eur J Neurol. 2014;21:731–5.
4. Pfiffner TJ, Jani R, Mechtler L. Neuro-oncological disorders of the cerebellum.
Neurol Clin. 2014;32:913–41.
5. Bataller L, Valero C, Díaz R, Froufe A, Garcia-Zarza A, Ribalta T, et al. Cerebellar
ataxia associated with neuroendocrine thymic carcinoma and GAD antibodies. J
Neurol Neurosurg Psychiatry. 2009;80:696–7.
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660
Letters to the Editor / Arch Bronconeumol. 2015;51(12):656–665
José Luis Serrano-Martínez,a,∗ Mónica Zamora-Pasadas,a
María Redondo-Ortsb
b Servicio de Cuidados Críticos y Urgencias, Hospital Universitario
Virgen de las Nieves, Granada, Spain
a
Servicio de Medicina Interna, Hospital Universitario Virgen de las
Nieves, Granada, Spain
∗ Corresponding
author.
E-mail address: jlserranomi@gmail.com (J.L. Serrano-Martínez).
Cortico-dependent Asthma: Our Clinical
Experience夽
Table 1
Clinical Progress and Treatment Modifications in the 10 Patients Diagnosed With
Corticosteroid-dependent Asthma.
Asma corticodependiente: nuestra experiencia clínica
To the Editor,
Corticosteroid-dependent asthma is defined as the need for
daily administration of oral corticosteroids.1 This definition, however, is ambiguous, since it includes both patients who receive this
treatment and experience little improvement, and those who benefit from it (with a varying degree of response). The GOAL study
showed that only 7% of patients who were uncontrolled at maximum doses of fluticasone/salmeterol achieved control with an oral
steroid regimen.2 Few studies have been conducted in this specific
patient group, despite their clinical relevance. We report the case
of a patient with corticosteroid-dependent asthma, and review the
management and progress of all corticosteroid-dependent asthmatics seen in our specialist clinic (10 of a total of 475 patients).
A 69-year-old woman, non-smoker, with a diagnosis of lateonset, non-allergic asthma, IgE 770 kU/l, eosinophils 900/mm3 ,
FENO 31 ppb. Asthma was initially poorly controlled with a
combination of maximum doses of budesonide/formoterol, as
indicated by asthma control test (ACT) 15, a severe exacerbation in the previous year, FEV1 64%, and positive bronchodilator
challenge. Significant comorbidities included rhinosinusitis and
obesity. Treatment with deflazacort 30 mg for 3 weeks increased
ACT to 23 and FEV1 to 67%, but when it was withdrawn, ACT
returned to 16 and FEV1 to 67%. Tiotropium (18 ␮g/day) was
added to the combination of fluticasone/salmeterol (500/50 ␮g),
but ACT remained unchanged, while FEV1 rose to 70%. Treatment
was subsequently switched to inhaled fluticasone (1000 ␮g/day),
tiotropium (18 ␮g/day) and indacaterol (150 ␮g/day). The patient
is currently free of exacerbations, her ACT is 24 and FEV1 is 79%.
In our opinion, a patient who is uncontrolled and presents
bronchial obstruction despite treatment with a combination of
maximum dose inhaled corticosteroids (IC)-long-acting ␤-2 agonist (LABA) has corticosteroid-dependent asthma. In the case of
our patient, her FEV1 normalized (at least to >70%) and ACT rose to
≥20 after 3–4 weeks of treatment with deflazacort 30 mg. Subsequently, when the oral corticosteroid was discontinued, her clinical
and functional status returned to the previous situation.
ACT
Exacerbations/patient/year
FEV1 %
Oral corticosteroids
Omalizumab
LAMA
Indacaterol
Initial
Final
16.9±3.8
0.32
53.5±14.2
0
0
0
0
22.5±2.7
0
76.4±13.3
0
2
10
7
ACT: asthma control tests; FEV1 %: forced expiratory volume in 1 second; LAMA:
long-acting anticholinergics.
sity, rhinosinusitis, and polyposis). Despite the correct use of
IC/LABA at maximum doses, these patients remained symptomatic
with signs of bronchial obstruction, yet only 2 developed 2 or
more severe exacerbations in a period of 1 year. It seems that in
most cases, standard treatment can prevent exacerbations, while
failing to provide full control of symptoms or normalization of lung
function. This was achieved in all cases when an oral corticosteroid
was added, although this treatment was unacceptable due to
adverse events.
These 10 patients were managed by the same pulmonologist. For
the 2 patients in whom severe exacerbations persisted, the treatment strategy consisted, firstly, of adding omalizumab to the regimen. The response of the patients who received omalizumab confirm its efficacy in reducing exacerbations, but also its lack of effect
on lung function.3 Persisting bronchial obstruction may explain
why optimal control of symptoms is elusive in many patients.
The next step for all patients consisted of adding a long-acting
muscarinic antagonist, a medication that has already demonstrated its efficacy in this clinical setting.4 This intervention helped
improve patients’ lung function and symptoms, but to an insufficient degree in 7 cases. We decided to add indacaterol to these 7
patients’ regimens: this potent bronchodilator has demonstrated
efficacy in chronic obstructive pulmonary disease, but little experience is available in asthma.5 This combined therapeutic strategy
resulted in a significant improvement in lung function and symptoms (Table 1) among corticosteroid-dependent asthma patients,
while avoiding the use of oral steroids.
Authorship
Clinical characteristics, treatment, and progress of patients
with corticosteroid-dependent asthma
Ten of our patients (of 475 regularly seen in our consulting rooms) had corticosteroid-dependent asthma. They were
typically middle-aged (49.2±15.1 years), with late onset of symptoms (7/10 cases), intense peripheral eosinophilia (eosinophils
565.0±286.8/mm3 ), elevated IgE (379.7±357.3 kU/l), FENO
(31.7±13.2 ppb), and significant comorbidities (particularly obe-
夽 Please cite this article as: Pérez de Llano LA, García Rivero JL, Pallares A, Mengual
N, Golpe R. Asma corticodependiente: nuestra experiencia clínica. Arch Bronconeumol. 2015;51:660–661.
Study concept and design, data collection, analysis of results,
interpretation of findings, and drafting the manuscript: Pérez de
Llano.
Study design and data collection: García Rivero and Pallares.
Data collection: Mengual.
Data analysis and interpretation of results: Golpe.
Conflict of Interests
Dr Pérez de Llano has received payment from Novartis,
Boehringer, Chiesi, Almirall, Esteve and Ferrer, for presentations at
medical congresses, consultancy, and coordination or participation